In an intestinal obstruction (ileus), the intestine is actually closed – as the name suggests – so that food remains can hardly or not at all be excreted. An obstructed intestine can manifest itself suddenly and dramatically, for example, when a piece of intestine becomes trapped in a hernia sac, or it can develop insidiously and discreetly, for example, in the case of a slow-growing, constricting tumor. But no matter which clinical picture occurs, intestinal obstruction is always a life-threatening emergency and must be treated immediately in the hospital.
Symptoms of mechanical bowel obstruction
An obstruction (tumor, fecal ball) that blocks the intestine is usually responsible for a mechanical bowel obstruction. It is also possible that the bowel is constricted from the outside, as in adhesions or as a result of an injury. The symptoms of an obstructed bowel can vary depending on the cause and severity. However, the following signs are generally noticeable:
- Bowel contents back up into the stomach, causing belching, nausea, and vomiting. In extreme cases, the patient must vomit feces (miserere).
- Pain is caused by violent, cramping and episodic intestinal contractions or a concurrent peritonitis.
- As a result of intestinal dilation, the abdomen is distended (meteorism).
Caution: in strangulated ileus, the affected section of the intestine is no longer supplied with blood. The pain then persists continuously, the blood pressure drops, the pulse accelerates and the patient vomits heavily (also stool). However, ileus often develops without pain and over weeks to months. In the case of mechanical intestinal obstruction, normal stool may well be passed if the location of the obstruction is high in the small intestine, since in this section of the intestine the stool is still liquid and the liquid can easily pass through the constricted section of the intestine. If the passage of food is not completely interrupted, but only restricted, this is referred to as a “subileus”.
Symptoms of paralytic bowel obstruction
Paralytic intestinal obstruction is caused by paralysis of the muscles of the intestinal wall. As a result, the intestinal contents cannot be transported further. Symptoms in the paralytic type are not as pronounced as in the mechanical type and appear delayed. Nausea and vomiting also occur, but since the intestine is paralyzed, no bowel sounds are heard. In medicine, this is referred to as “sepulchral or dead silence.” The pain is permanent and diffuse, so that the patient cannot clearly say where the pain is coming from. Particularly characteristic of a paralytic bowel obstruction is the distended abdomen, which in the case of additional peritonitis can become a so-called hard and tense “drum belly”. As it progresses, the patient may vomit liquid intestinal contents.
Intestinal obstruction: diagnosis
If the patient’s condition permits, a detailed history is taken. Evidence of repeated stomach ulcers, cramp-like pain that occurs immediately after eating (evidence of mesenteric infarction), or pain in the right lower abdomen (for example, from appendicitis) may be helpful in narrowing down the various causes and initiating the necessary investigations. Asking about the nature of the pain provides information about which organ might be affected. Sudden, sharp, stabbing pain in the right upper abdomen is more likely to indicate gallbladder inflammation or duodenal ulcer. If this pain radiates to the right back, then it may be gallbladder inflammation. Therefore, describing the exact extent of the pain is as important as describing the nature of the pain.
Further examination by the physician
The medical history is followed by physical examination findings. Often, a person affected by bowel obstruction appears restless, and his or her legs may be bent to reduce tension in the abdomen and allow relief. On examination, a defensive tension of the abdomen can be detected. This either occurs at a specific point or is distributed throughout the abdomen. The abdomen is often generally tender to pressure. Bowel sounds can be assessed with a stethoscope. Metallic-sounding bowel sounds indicate mechanical ileus.Absence of bowel sounds, on the other hand, indicates a paralytic bowel obstruction. Rectal examination (palpation of the rectum with a finger) can be painful, especially if appendicitis has caused irritation of the peritoneum.
Imaging examinations
X-rays are taken while the patient is standing or in the left lateral position to evaluate the abdomen. Crescent-shaped air and fluid collections can be seen in bowel obstruction. Depending on involvement, they are called small bowel or large bowel. Free air under the diaphragm is a sign of a “leak” in the gastrointestinal tract; often the air leaks through an inflamed and leaky mucosal area. Ultrasonography (sonography) can be used to narrow down the cause of the bowel obstruction. Pendular peristalsis (intestinal contents are no longer transported) indicates mechanical bowel obstruction and lack of peristalsis indicates paralytic bowel obstruction. Computed tomography is performed as a complementary examination to evaluate the internal organs.
Revealing by values in the blood
Depending on the cause of the bowel obstruction, many blood values may be abnormally altered. The blood count allows determination of white (leukocytes) and red (erythrocytes) blood cells, the red blood pigment hemoglobin, and platelets (thrombocytes). Blood loss causes a decrease in hemoglobin. Inflammation, on the other hand, causes a significant increase in white blood cells. The erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase (LDH) are increased. In addition, liver enzymes and pancreas levels may increase abnormally. As the disease progresses, coagulation values also worsen.
